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Episode Transcript

Okay, let’s be honest: how much of what you know about medicine, especially emergency medicine, comes from watching TV?

E.R. CHARACTER 1: Gunshot wound’s on its way.



Hospital dramas have long been a staple of the Western media diet.

E.R. CHARACTER 1: Blake, find Benton. Clear trauma one and notify the O.R.

And research shows that we tend to believe what we see on fictional TV shows. One Belgian study, for instance, found that people who watch a lot of hospital dramas are more likely to overestimate the likelihood of survival of a real-life patient after receiving CPR.

E.R. CHARACTER 1: He’s not breathing. Get the intubation tray.

But overall, is a patient in a TV hospital more or less likely to die than a real patient? That was the question posed by Amir Hetsroni, an Israeli professor of communications, who did some research on American TV dramas. He and his students watched episode after episode of E.R.Chicago Hope and Grey’s Anatomy, keeping detailed coding books on every patient — their race, approximate age, their malady, the treatment — and whether they lived or died.

Noah WYLE playing Dr. John Truman Carter III in a clip from E.R.: Mark died this morning at 6:04 a.m.

And what did Hetsroni find?

Amir HETSRONI: People die on TV in TV hospitals far more than they die in real life.

That’s right, people in TV hospitals die a lot more than they die in real hospitals. Hetsroni found that TV patients were nearly nine times more likely to die than if you or I wound up in an E.R. The medical problems of the TV patients were also more dramatic. Injury and poisoning, for instance, were about four times more common on TV than in real life. Same for mental illness.

Demi LOVATO as Hayley May in a clip from Grey’s Anatomy: I’m not crazy. I’m not crazy.

Amy FARRINGTON as Mary May in a clip from Grey’s Anatomy: It’s okay. Hayley, honey, the doctors are going to help you.

Justin CHAMBERS as Dr. Alex Karev in a clip from Grey’s Anatomy: You paged surgery?

Regi DAVIS as Dr. Kevin in a clip from Grey’s Anatomy: Hayley May, 16, diagnosed paranoid schizophrenic. Tried to claw her eyes out. I need you to clear her before I can take her up to psych.

Some conditions, meanwhile, are vastly underrepresented on TV: heart failure, heart disease, and stroke were roughly one-third as common on TV as in real life. Cancer is also under-represented. And then there are the patients. Hetsroni found that a typical TV patient is more likely to be white, male, and young than a real patient. About a third of real patients are 65 or older, whereas hospital dramas are crawling with young patients. TV patients are also presumably much better-looking, although Hetsroni did not measure this in his research. He did, however, make one more observation: that doctors on TV today are no longer viewed as infallible, like they used to be. They make mistakes; they make bad decisions under pressure; they are human — just like doctors in the real world. And just how fallible is the real-world medical profession? That is one of the questions we’ll ask in this week’s episode.

Jeffrey BRENNER: When you read medical history, it’s very humbling. We have screwed stuff up and hurt people over and over and over, and we’ve done it with our arrogance.

And we are consuming more and more health care — maybe, in part, because we see so much health care dished out on TV. But is more better?

Anupam JENA: The perception of health care is that by doing more we can improve health. It’s not black and white. And it could very well be the case that in the gray, less may be more.

And one more question: what do you think happens when a significant portion of America’s cardiologists go away at the same time, to a medical conference? Do you think a lot more heart patients die during their absence – or maybe, just maybe, the opposite?

*      *      *

Our previous episode was about how people are increasingly using RCTs, or randomized controlled trials, to sort out all kinds of problems.

Steven LEVITT: The randomized trial is the very best way to learn about the world around us.

Especially a problem like how to improve health care delivery.

Amy FINKELSTEIN: Let me start by telling you an interesting story, which is the Oregon Health Insurance Experiment.

We also learned about “super-utilizers” — those are the patients who consume way, way, way more than their share of health care.

BRENNER: Yep. We learn that 1 percent of the patients is 30 percent of the payments to the hospitals. 5 percent of the patients is about 50 percent of the payments to the hospitals.

And we asked if one way to help these super-utilizers — and the rest of us — would be to enroll them in an intensive intervention:

BRENNER: And if they’re interested, we consent them. We then walk out of the room. It’s a randomized control trial. We’re testing the intervention and we hit the random button.

The conversation began pretty narrow, about RCTs. But soon it went wide — and it began to turn into an indictment of our overall health care system. So this week we are continuing that conversation, with a new set of questions. We assume that if you’re not getting health care, you’re worse off — but is that necessarily the case? How much care is too much care? And when you start to peel a few layers off the U.S. health care system, how does it really work? And who does it really serve?

BRENNER: The most dangerous thing in America is an empty hospital bed.

This conversation is made possible by the fact that our health care system generates an enormous amount of data. Innumerable inputs. Innumerable outputs. For us laypeople, that can seem like a nightmare; for an economist, it’s a dream. For there’s a lot to be learned from a clever and robust analysis of all that data. Consider the data collected through Medicare, the government-run program that provides coverage primarily to Americans 65 and older.

JENA: Anytime a Medicare beneficiary receives any care, whether they see a doctor in an office or whether they’re hospitalized, a claim is filed to Medicare for billing purposes.

That’s Anupam Jena. He’s an assistant professor of health care policy and medicine at Harvard Medical School, and he sees patients one day a week at Mass. General:

JENA: Bread and butter cases like pneumonia, COPD, heart failure, the typical hospital admission.

But Jena isn’t just an M.D.; he also holds a Ph.D. in economics.

JENA: It’s becoming more common. I would say there’s probably 10 to 15 of us at most in the U.S.

That dual training has very much informed the way Jena thinks about his work. When he was doing his residency, for instance, in internal medicine, a question came to mind: How helpful were the medical procedures being carried out by his elders?

JENA: In some instances it was pretty clear, at least to the residents in training, that a procedure may not have been appropriate for that patient.

Jena also wondered about the differences between doctors in a given hospital.

JENA: And that got me thinking, “What happens to patients when certain doctors aren’t around? Or when, let’s say, doctors go away to conferences. What happens to their patients during those dates?”

Yeah, what does happen to patients when doctors go to medical conferences? When the doctor’s away, does the patient pay? Let’s think about cardiology, heart medicine. Every year, there are two major conferences for cardiologists in the U.S.: the American Heart Association conference, usually held in the fall, and the American College of Cardiology, or ACC conference, typically held early in the year. This year, it was in March, in San Diego — a nice place to be after a long cold winter back east. Out of the 30,000-plus cardiologists in the U.S., more than 7,000 of them are estimated to be at each of these two meetings.

JENA: It’s not a small number of cardiologists that attend. The purpose is to present new research findings, to hear about old research findings, to re-certify [and] to get more information about what’s up to date in the field.

Jena thought he knew what might happen to heart patients during these conferences. There have been a number of studies, he says, about what happens to hospital patients during off-peak hours.

JENA: If you’re hospitalized after midnight, or if you’re hospitalized on the weekend, as a patient, do you have worse outcomes? The answer in most studies has actually been yes. Not all, but most of these find that patients receive…

Stephen J. DUBNER: They have worse outcomes?

JENA: Exactly. Worse outcomes if you’re hospitalized during off hours. That was a natural stepping stone to say, “What happens if you’re a patient and you happen to be hospitalized with a really acute condition when cardiologists are out of town at a national meeting?”

To answer that question, Jena, along with three co-authors — Vinay PrasadDana Goldman, and John Romley — turned to the Medicare data.

JENA: When a Medicare beneficiary dies, that information is also reported back to Medicare. What that information allows us to do is to say, “When are they hospitalized?” Meaning, “What date are they hospitalized? What happens to you after you leave the hospital? Do you go to a skilled nursing facility? Do you go home? Do you make it past 30 days? Are you dead within 30 days?” All of that information is available for researchers to analyze.

They began to overlay patient data with the dates of the cardiology conferences, covering a ten-year stretch. They looked at patients admitted during those conferences and, for comparison’s sake, patients admitted in the three weeks before and after those conferences. They narrowed their analysis to the patients who were in really bad shape.

JENA: The idea is, we want to pick conditions where a patient doesn’t choose to not come to the hospital because their particular doctor is away, or because they have some knowledge that cardiologists are away during this time. We wanted to pick three really acute conditions. The first was cardiac arrest. Cardiac arrest is a condition where your heart stops beating completely.

DUBNER: Whoops, hang on one second.

Let me just say we were speaking to Jena back in February. I was in New York and he was in Boston, which had just been hit by yet another monster snowstorm.

DUBNER: Hang on one second. I was hearing some background sound, like a truck or something.

JENA: Yeah, that was a snowplow that just went by.

You may hear a few more snowplows before this conversation is over. Okay, back to Dr. Jena and cardiac arrest.

JENA: Cardiac arrest is a condition where your heart stops beating. It’s not a condition that someone chooses to have. It just happens to you. By definition, you die and you’re brought back to life. It is the most acute thing that you can imagine happening to you.

Jena and his colleagues also looked at heart failure.

JENA: And heart failure, as you might know, comes in a number of varieties. But we looked at patients who have really severe heart failure. To give you a sense of the numbers involved, about 30 percent of these patients are not alive within 30 days of hospitalization. It’s a pretty acute condition. A high mortality condition. The last condition that we looked at was heart attack. The medical term is acute myocardial infarction, but it’s basically when one or more of the arteries that supply your heart has an acute blockage and so blood doesn’t go to your heart. Again, the same kind of mortality rates. 30 percent mortality almost at about 30 days.

The Medicare data covered tens of thousands of hospitalizations for these three conditions over the 10 years’ worth of annual cardiology meetings.

JENA: It’s about as close to a randomized control trial as you could ever hope to get. These patients are nearly identical on meeting and non-meeting days. They’re the same age, the same sex, the same race. We look at 10 different chronic conditions that they have. They have identical percentages of each one of them. They’re basically the same.

So what did Jena and his colleagues find? How did the cardiologists’ absence affect patient outcomes?

JENA: We just assumed that the decreased availability of doctors would imply that outcomes would be worse. That was our initial hypothesis. And what we found was the opposite.

The opposite — meaning that patients were less likely to die while the doctors were away. But only, we should point out, for certain high-risk patients in certain kinds of hospitals. Jena and his colleagues looked at teaching hospitals and non-teaching hospitals; the assumption is that teaching hospitals have more of the type of cardiologists who are likely to attend conferences, but that’s only a hunch. And that is where Jena found the surprise in his data. In non-teaching hospitals, the conference didn’t seem to matter. But patients who were admitted for cardiac arrest to a teaching hospital during one of the cardiology conferences were roughly 10 percentage points more likely to survive than if they were admitted on non-conference dates. Patients with heart failure — again, at teaching hospitals — were eight percentage points more likely to survive during a cardiology conference.

JENA: High-risk heart failure. What we found is that if you’re hospitalized on a cardiology meeting date, your mortality is about 17 percent at 30 days, 17-18 percent. Whereas if you’re hospitalized just a few days before or a few days after, your mortality is closer to 25 percent. That’s a very large difference.

DUBNER: Wow. It just sounds so absurd. I’ve read the paper, I know what you’re going to say, but it still sounds so absurd. Basically, if I have a major heart condition and someone gets me to a good teaching hospital — I live in New York, my hospital is Columbia Presbyterian, that’s a great teaching hospital. You’re saying that I have a better chance of surviving if there’s a cardiology conference going on and some of the top cardiologists are not there.

JENA: That is correct.

DUBNER: Okay. Describe for me, overall, the magnitude of this effect compared to, let’s say, standard cardiology treatment — whether it’s beta blockers or statins, angioplasties, stents. How much better off are you by having those interventions than you are by just simply going to the hospital when the cardiologists are not there?

JENA: The mainstays of treatment for heart disease are beta blockersstatins, aspirin for some individuals, a blood thinner like Plavix. If you were to combine all those therapies together, we’re probably talking about reducing your mortality by about two to three percentage points.

DUBNER: Wow, percentage points. Okay. Here you’re talking about eight percentage points in one case and 10 percentage points in another.

JENA: Exactly. These treatments are very effective but they’re not nearly as large in magnitude as what we’re finding here.

Another finding in Jena’s paper: while patients with cardiac arrest and heart failure were less likely to die during a cardiology conference, there was no difference in outcome for patients who were admitted with a heart attack. The study did find, however, that these patients received far less invasive treatments — stents and angioplasties, for instance — when many cardiologists were away.

JENA: An angioplasty is a procedure in which a balloon is inflated in one of the arteries that supply the heart. It basically opens up the blood vessel that was clogged. That is different than stenting. Stenting is a procedure in which an actual stent is placed in the heart and opens up the artery. It keeps the artery open. There’s nearly a third reduction in rates of angioplasty, stenting during meeting days. Remember, in heart attacks we didn’t find any difference in mortality. At the very least, what this would suggest is that we’re able to reduce these procedures by about a third, and yet we see no difference in mortality in heart attacks.

DUBNER: What does the empirical research say about the efficacy of, say, angioplasty? In other words, we hear about these invasive treatments — angioplasty and stenting and so on — and we, the public, like to think that if doctors have gone to the trouble and researchers have gone to the trouble to come up with these things, of course they work really well. Not only to come up with these things, but to use these things and to build for these things, and so on. But talk to me for a moment about what we actually know or maybe don’t know about the efficacy of such interventions.

JENA: These interventions — for example, stenting or angioplasty — are extraordinarily effective. If you look at the interventions that have been developed in the last thirty years for heart disease, they rank at the highest in terms of their innovativeness and their effectiveness. Most of the patients for whom these interventions have been studied have been what I would characterize as average- to moderate-risk patients. There have been some studies with very severe coronary artery disease, very sick patients for whom these interventions have been studied. Even in those studies, they do find average benefits for these procedures. By and large, if you were to look at this study without any information about the results, you would think to yourself, “By lowering rates of these invasive procedures, we are likely to harm patients.”

But, as we know, that’s not what the study found. Jena admits that, given the data, it’s impossible to point to an exact cause.

JENA: The strongest limitation of the paper is that we can’t tell you exactly what’s going on. What I can tell you, with close to certainty, is that something is happening in the hospitals that is responsible for the lower mortality on meeting days.

And keep in mind, it’s not as if there are no cardiologists in hospitals during annual meetings. Some docs cover for others; more junior staff might take over for a few days. Jena suspects that the doctors who stay behind may be more cautious.

JENA: What we’re identifying is, that group of patients for whom the cardiologists who are left behind may have thought to themselves, “This person may not be appropriate for this procedure.” The clinical decisions that they’re making are different now. They could be different in a way that actually improves outcomes, because they’re restricting procedures for those who are at the margin, who would be least likely to benefit.

DUBNER: And your explanation would be that these are docs who are covering — who might be more junior, whatnot — they are less likely to order up what a more senior, confident, experienced doctor might order up. Is that one explanation?

JENA: That’s one explanation. Another explanation could be that the covering doctor says to himself or herself, “Look, I don’t want to do this thing because I’d be better off not harming the patient by doing a procedure. Why don’t I just wait and see what happens? Simply because this is not my patient, I’m covering the patient for somebody else.”

And this, Jena says, brings us to the “less is more” dictum in medicine — which, he notes, is not universally embraced.

JENA: The perception of health care is that by doing more we can improve health. What we need to recognize is that so much of health care — so many of the clinical decisions that we make — operate in this gray zone. It’s not black and white. And it could very well be the case that in the gray, less may be more.

DUBNER: Could it be that the doctors who are most likely to attend these conferences are those who are involved in research, and that they, perhaps, aren’t as good at clinical care, and the ones who are left behind are maybe better? Is that a possible explanation?

JENA: That’s a possible explanation. The reason that we find our results predominantly in teaching hospitals is because if you look at the fraction of academic cardiologists who attend these meetings, and you look at the fraction of community cardiologists who attend these meetings, the share would be larger among academic cardiologists. We haven’t been able to get any great data from the American College of Cardiology, or American Heart Association, but whatever data they do publish online would support that. That’s why it’s not surprising that we saw the effects there.

DUBNER: I’m curious, Dr. Jena, have you heard from either The American Heart Association or the American College of Cardiology, the two conferences that you measured?

JENA: Not formally. The American College of Cardiology released a statement, which was very well-worded. It basically said, “It’s reassuring to know that during dates of national cardiology conferences, our patients receive no worse care.” Which is technically true.

DUBNER: Technically true. But I could see them playing it either way. They could take it as an indictment that they represent a bunch of people who don’t contribute to better care. On the other hand, they could say, “Hey, our conference is a major life-saver. We draw away all these people who are doing too many procedures, and that’s saving a lot of lives.” But I can’t imagine they’ll turn that into their slogan. Would you?

JENA: Exactly. I’ve tried to advocate that to my own chair to let me go to more conferences, but that hasn’t worked.

We did ask the two organizations to respond to Jena’s study. Richard Chazal is the ACC’s vice president and a practicing cardiologist.

Richard CHAZAL: Many of us were actually reassured that there wasn’t an increase in risk during these meetings, because many people had hypothesized that might be the case — that when there was a departure of some physicians, that the staffing levels could result in an increased risk. I do think it’s reassuring to the public — and to you, and to me — that we can safely get our care at a teaching hospital during periods of time of meetings. That part is encouraging.

Pretty much as expected; Dr. Chazal did add this, however:

CHAZAL: This is important and interesting information. The biggest concern here, and the one that we have to look at is this finding, to try and tease out if we can, in the future, why that is and how we modify our behavior so we have a lower risk at all times.

The American Heart Association, meanwhile, sent us a recorded response from its president, Dr. Elliott Antman — we weren’t allowed to interview him. Dr. Antman says there is no evidence of cause and effect in Jena’s study, and that we should essentially think of it as a “calendar analysis.”

Elliott ANTMAN: The investigators happened to analyze the period of time when cardiology meetings were occurring. They could have picked Christmas. They could have picked New Year’s or Easter. We know that there are changes in the staffing schedule when there are holidays, when there are important national cardiology meetings. Bottom line for us at the American Heart Association: there’s nothing in this study that we see that would lead us to recommend a change in clinical practice.

In my interview with Jena, I had raised the same point:

DUBNER: Okay. Is it possible that these cardiology conferences are perhaps typically held at the same time of year every year, which might be the same time of year that coincides with lower mortality?

JENA: That is definitely possible, but as it turns out, over the nearly 10 years that we looked at the data, the cardiology conferences actually varied in their time. It wasn’t that they were always at the same time of the year. They actually do vary slightly from week to week across the 10 years.

DUBNER: Right. I’m curious, has there been any similar research with psychologists or other mental health professionals? I’m wondering if anyone has ever looked at suicide, hospitalization, or even depression outbreaks — if such a thing could be measured — during psychiatric conferences, or maybe even just during August when all the shrinks in New York go to Cape Cod?

JENA: No, that’s a great question. I’m not aware of any. I’ve actually looked into this to see whether or not there was anything that was done. It’s something we’re going to do — if it hasn’t been done — after an exhaustive search. But it’s a great example. I’ll give you another example of something we have actually looked at, which we do know data about and I’m sure you’ve heard about, is this ‘July Effect.’ It’s the idea that patients who are hospitalized in academic medical centers in July have worse outcomes because the residents who are there are inexperienced. By and large, what this literature has found is that the July Effects, if they happen, are very small. The question for clinicians was always, “How is that possible? How is it possible that something that every clinician thinks to be a big issue turns out to not be a big issue when you look at the data?”

The insight that we had is that every patient who comes into the hospital is different. For most patients, it really does take a lot to lead to an adverse outcome. What happens if you focus on those patients who are the most sick? What we did is look at the same group of patients. We looked at patients who had heart attacks, who are in the top third of predicted mortality. These patients have a mortality rate of about, as I said, 25 [to] 30 percent. What you see is that, for those patients, there actually is a July Effect. If you’re hospitalized in a teaching hospital with a very severe heart attack, you are five percentage points more likely to die if you’re hospitalized in July versus May. Basically, 25 percent mortality versus 20 percent mortality. It’s a large effect.

Of course, it goes in the opposite direction of what we’re saying here, in the sense that less is worse, but that’s one example of people looking at what happens around specific times of year, or specific types of practices.

DUBNER: How do you account for that contradiction?

JENA: The contradiction is going to be: what is the clinical decision that’s being made. I keep on coming back to this in my mind: Why is this happening? All I can come down to is I think that cardiologists are just making different clinical decisions during non-meeting dates. The decision that’s being made: is this patient appropriate for a procedure? Because whenever you do something, you have to have in your mind, “Is this person good or bad for it?” Let me give you another example. If a cardiologist had 100 procedures to allocate, and that’s all they could do, I’m fairly confident that each one of the people that they allocated those 100 procedures to would do extraordinarily well. They’d have a beneficial outcome. But there is no constraint like that in reality. You can go to the 100 first, the 100 second.

DUBNER: That’s such an interesting way to think about it. It makes me think that the economist part of your brain is intruding on the medical part of your brain there. I wonder if you’re leading to some relationship between cost, treatment, availability, supply, demand and so on. Forget about just cardiology for a moment. Do you think that’s a major component of adverse outcomes that we’re looking at generally, including the fact that we spend a larger share of our GDP than any other country on earth for health care, and yet our outcomes are super sub-optimal. How much do you think that is due to a almost an endless supply and a relatedly very high demand?

JENA: The common concern is that because doctors are paid fee for service, meaning they get paid for every procedure that they do, that it leads to over-incentives for them to do procedures. I’m actually not convinced that that is really the root of all the quality problems that we find. My hunch is that the reason that physicians may be doing more procedures than is clinically optimal is that they just don’t know any differently. If you think about what is it that impacts a physician’s decision — well sure, what they get paid impacts it, just like it would impact any one’s decision — but what about where they went to medical school? What they learned during residency? Whether or not they’ve been sued before? And, most importantly, what is their level of risk aversion?

I’ve got to imagine that that would translate somehow into clinical practice. There are underlying differences in how people think, how doctors think, that drive these decisions.

Ah, now we are entering a slightly different realm – what’s generally called “evidence-based medicine.” We will get into that after the break.

BRENNER: And, what I think many people would be shocked to find out, is that many of the things that we do with day-to-day care actually have very little evidence for them.

But we are getting better, aren’t we?

BRENNER: We have a really deep problem with how we’re training doctors. They are not being trained to be critical thinkers.

That’s coming up on Freakonomics Radio. But before we take the break, let’s hear what some practicing cardiologists had to say about Anupam Jena’s paper, which was published in the JAMA journal Internal Medicine.  A few weeks ago, we sent a producer to the annual meeting of the American College of Cardiology, or ACC, in San Diego. That is one of the two big annual conferences that Jena analyzed. The first thing we wanted to know is what kind of impression the paper has made:

Kurt KOHNEN: Have you heard of this study?

Ariel PIMENTEL: No, I haven’t. But I don’t think that it might affect the mortality of the patients while they’re away, because normally in the hospitals there are plans to cover for the absence of the cardiologists.

Khidir OSMAN: I hope it’s not affected at all, because before they leave I’m sure they have somebody covering for them.

Lynn PUNNOOSE: Right now, my partners are covering for me while I’m out here. So I know my patients are getting excellent care and coverage while I’m not able to see them directly. I’m assuming that’s the case for everybody.

KOHNEN: What would you say if I told you the study found that there were actually less deaths during the conference? The mortality rate improved while everyone was away.

OSMAN: That is very surprising actually.

PIMENTEL: I wouldn’t expect that, that mortality is lower. I would expect that when everybody is working at the hospital, the quality of care is better. That’s the normal thing.

Pablo TORO: You should think the opposite right? You should think the less doctors, the more dies right? But it’s interesting.

Marye GLEVA: Well, we would have to look at the methods of the study to see how robust it is.

Pierangelo RENELLA: It just doesn’t make sense to me that less access to a physician or less access to medical care would make things better. Not having reviewed the study and the methodology, results from studies like this have to be taken with a grain of salt. Just because you have an association — as scientists we all know that that does not mean there’s causation.

Victor SOUKOULIS: I have heard of this study. It’s a running joke in the department that they should pay more money to send us to conferences to improve outcomes in our hospital. But if you had asked me before, I wouldn’t have guessed that that would be the result. I probably would have guessed there’s no difference. If you’re the person that’s left over when everyone is at the conference  — it’s a time when there’s fewer tests that can be done. People aren’t available. It takes longer to get things done, and it makes us wonder if it’s a little bit better sometimes not to have easy access to all the technology right away. Sometimes it might be better to slow things down and see how they evolve.

PIMENTEL: Sometimes, in the cardiology field, the intensity of care can be aggressive, and maybe sometimes some procedures are done without being strictly necessary.

OSMAN: It very interesting that the quality improved and the mortality went down. Maybe they need to stay at the ACC in San Diego.

KOHNEN: Check, check. Start with your name, your title and where you practice.

PIMENTAL: My name is Ariel Pimental. And I’m a cardiologist and I practice in Santo Domingo, Dominican Republic.

OSMAN: My name is Khidir Osman. I’m an interventional cardiologist. Yuma, Arizona.

PUNNOOSE: I’m Lynn Punnoose, assistant professor of medicine at Temple University.

TORO: My name is Pablo Toro. I’m coming from Honduras, Central America, and I’m internal medicine practicer.

GLEVA: Marye Gleva. I am an associate professor of medicine at Washington University in St. Louis, and I am an electrophysiologist.

MEJIA: Victor Mejia, practice in Louisiana, a cardiologist.

RENELLA: Pierangelo Renella, a pediatric cardiologist out of Orange County and at UCLA.

SOUKOULIS: I’m Victor Soukoulis. I’m an attending cardiologist at the University of Virginia.

*      *      *

In our previous episode, about the use of randomized controlled trials in health care delivery, we spoke with Jeffrey Brenner. He’s an M.D. in Camden, N.J., one of the poorest cities in the U.S. He’s a family doctor.

BRENNER: I see kids, adults and deliver babies.

Brenner also founded the Camden Coalition of Healthcare Providers. It works with low-income patients to coordinate their care among a network of medical and social-service organizations. The Coalition’s overarching goal, Brenner says, is to improve care while also reducing costs.

DUBNER: That sounds like an admirable goal. It also sounds like what should be a common goal within the health care profession. Is it, in fact, a common goal to deliver health care for less money?

BRENNER: Not at all. The major imperative for most organizations in health care is to get bigger and bigger. Money is like fertilizer. The way you get bigger is getting more money, more market share, more customers.

Brenner believes that the practice of medicine has been subsumed by the business of medicine. The activities that are incentivized, he believes, aren’t necessarily good medicine. This doesn’t leave much room for doing something as basic, and helpful, as a doctor sitting down and talking with patients.

BRENNER: That’s why I went into family medicine. I love to get to know my patients and talk with them. I’ve always felt that the trick to healing, wellness and changing behavior is relationship-building; having a trusting relationship with someone who walks through the journey of life with you and helps nudge you in various directions. That requires really talking with people.

But the current health care business model discourages that, Brenner says.

BRENNER: In our system we have an asymmetry in price. We pay a whole lot of money if you cut, scan and hospitalize patients. If they have procedures, if they go through machines, we pay an enormous amount of money for those things. If you talk to a patient, you actually lose money in many instances. When a cardiologist walks in the room and talks to your family member, that’s actually a loss leader. That doctor is losing money every moment they stay in a room with your family member. The way they make money is by getting you out of that room back into the scanner that they’re leasing in the back of the office. That’s not their fault. That’s the fault of how we’ve structured the incentives in the system.

Spending time talking with patients might just seem like a feel-good connection, but Brenner says it provides real benefits that aren’t currently factored into the system.

BRENNER: We know that lots of people walk out of doctors’ offices every day in America and really have no idea what the doctor said to them. We know that we have lots of safety errors, we have a lot of medication confusion. I would argue a  lot of those things are tied to communication as well. We know that, in Medicare, that 25 percent of Medicare recipients are readmitted within 30 days. I would say a part of that is communication failure, that often times when patients leave the hospital they have very little understanding of what physicians said to them.

Brenner is a proponent of what’s known as evidence-based medicine. Like Anupam Jena, who found that cardiologists’ absence leads to lower mortality, Brenner believes that a wise use of big data can lead to massive improvements in health care delivery, but that we aren’t there yet. We aren’t even close to there yet.

BRENNER: Many people would be shocked to find out is that many of the things that we do in day-to-day care actually have very little evidence for them. They are habit that has been passed down from one generation to the next, but doesn’t have literature backing it up. Building out research literature in medicine is expensive, it’s complicated, it’s difficult. Even once you’ve got the literature built out, moving that literature into practice can take 10 to 15 years. There is so much information overload now that doctors have a hard time even keeping up with all the evidence. We have a problem generating enough evidence and funding, and then we have a metadata problem of: How do we synthesize all the evidence and make sure that it’s available to doctors every day when they need it?

DUBNER: I’ve always wondered: do you think that the reluctance to pursue evidence — to gather data in the realm of medicine — is in part because the history of medicine, the history of becoming a doctor, encourages doctors to think of themselves as — not necessarily godlike — but somewhere between humans and God, and that the evidence can be an implicit challenge to their wisdom, authority, intuition and so on?

BRENNER: What you are describing is absolutely correct. There’s even a deeper problem, which is that medical training bypassed The Enlightenment almost altogether. If you look back in the roots of medicine as training, as a pedagogy, it goes back to Greek tradition. In that Greek tradition, it was a lot of memorization and it was fealty to authority. It was a tradition that was passed down through the generations. It was almost like a priesthood. Med school is really like being inducted into a priesthood of power, money and influence. The Enlightenment was really about self-critical thinking, use of rational thought and the scientific method to prove and disprove things in an objective way. Very few physicians really understand the scientific method. You don’t necessarily have a science degree to go to med school.

When you’re in med school, most of med school is just memorization. If you look at how medicine is taught, the first two years are mostly memorization. Then the second two years are rounding on patients with senior physicians in a very steep hierarchy, where you learn to do what you’re told and you don’t challenge or embarrass the senior physicians.

DUBNER: It sounds like what you’re describing is a situation where, in health care or in health care delivery, you’ve got the potential generation of millions, billions, trillions of data points, because there are a lot of inputs and a lot of outputs. Yet it sounds as though most of the practitioners within that scenario aren’t really that, either concerned with, attuned to or at least practiced in the assimilation of all that data and what it can tell us, yes?

BRENNER: That’s very true. They’re not trained in critical thinking skills that would enable you to pull that evidence apart. Nor are they trained in, now, a very deep literature and psychology about how distorted evidence can be when you explain it to people, around all of the implicit biases that you can set up in decision-making. You would not only want to train people in how to interpret evidence, but then you would also want to train people in the communication skills necessary to describe risk to patients. Many of these discussions really revolve around helping patients understand risk and those are very hard concepts to explain. There are tremendous ways that doctors can bias those conversations. We don’t do a good job of that. Nor are we paid in a way that would even encourage you to have those conversations.

DUBNER: Can you give an example of that conversation where you’re trying to deliver a message: how it can be misinterpreted, or just not heard?

BRENNER: My favorite example recently is about mammograms. For women 40 to 50, mammograms do not save lives. Boy, that’s a staggering thing to say. We had been told as a society that, go get your mammogram, it will save your life. Our best statistical evidence is that mammograms 40 to 50 will not save your life and actually could cause you harm. There were plenty individual anecdotes that may say otherwise. But it’s likely that the cancers that were discovered for people 40 to 50 will regress on their own and are not life threatening cancers. That’s a really hard idea to get your head around. You have some ridiculous statements by physicians in the media that really show a misunderstanding of how to interpret statistics and data, which are frightening.

It’s not that different than doctors 200 years ago defending bloodletting, and then 100 years later the biggest argument in Europe was whether or not to wash your hands. The leading cause of death in Europe was infection during childbirth. It took 100 years to get doctors to wash their hands based on evidence. Then we turn the clock even further forward. We hurt a lot of people with thalidomide. We hurt people with calcium channel blockers. We hurt people with inappropriate use of arthroscopy, of angioplasty. We’re still hurting people today by using treatments that are not evidence-based and that are not statistically valid, treatments for which we have literature that they shouldn’t be using these treatments. We have a really deep problem with how we’re training doctors. They are not being trained to be critical thinkers.

I’m a huge student of medical history. When you read medical history it’s very humbling. We have screwed stuff up and hurt people over and over. We’ve done it with our arrogance. We’re still doing it, unfortunately.

DUBNER: Economists, health care economists particularly, would say, “A lot of the problems with health care and health care delivery is created by inefficiencies in the market, and if you just let the market work the way the market should work, then things would get better and things would get cheaper.” Do you agree? Is that a solution or is that not the solution to the problem as it now stands?

BRENNER: It’s a very idealistic solution. But the ultimate market inefficiencies are created by asymmetries of knowledge, where the customer doesn’t have perfect knowledge about what they’re buying. Either they don’t have price knowledge or they don’t have knowledge about the product. The irrational marketplaces of health care put me out of business. I was happily going to work everyday taking care of poor people in Camden, had a small three exam-room office, loved my job and loved my office. My office is currently boarded up and closed. It’s closed because the market didn’t work. The Medicaid rates kept dropping in New Jersey. By the time I was closed, I was getting sometimes $19 to $35 per visit. It’s impossible to keep the lights on and pay the overhead. The irrational marketplace of health care didn’t work.

That is, it didn’t work for him. Big hospitals, meanwhile, get bigger. And with that supply, Brenner says, comes demand.

BRENNER: One of the problems is that we have a giant economic bubble underlying this, where we have hospital financing authorities underpinning, that are run by states that help hospitals float bonds. We have this giant bond market called the hospital bond market that’s considered very secure, very safe, good investment. That bond market has floated too much hospital capacity and created and brought online too many hospital beds, far more hospital beds than we need in America. The most dangerous thing in America is an empty hospital bed. In the center of New Jersey, near Princeton, a couple years ago, we built two brand-new hospitals. These are two $1 billion hospitals, 10 miles apart, very close to Princeton. One is called Capital Health, and the other is Princeton Medical Center.  

I don’t remember anyone in New Jersey voting to build two brand-new hospitals. But we are all going to be paying for that the rest of our lives. We’ll pay for it in increased rates for health insurance. And, boy, you better worry if you go to one of those emergency rooms, because the chances of being admitted to the hospital when there are empty beds upstairs that they need to fill are going to be much, much higher than when all the beds are full — whether there’s medical necessity or you need it or not. I’d be very worried if you live in Princeton that there are now two $1 billion hospitals waiting to be filled by you.

But a system like this one, Jeffrey Brenner argues, is unsustainable. Or maybe, we should say that he hopes it’s unsustainable.

BRENNER: There comes a point in a democracy when the public’s had enough and they stand up and they get upset. The baby boomers shifted every public system they’ve ever touched. They shifted schools, colleges and universities. They changed the institution of marriage, of child rearing, of employment. They’re probably going to change the institution of aging, medical care and dying, ultimately. You’re starting to see lots of dialogue emerging about how people want to die. It would not take very much change in taste and preference to collapse the system. It’s become so brittle, so overwrought, so over-bonded and so over-capacity that the next great American bailout could be our academic health centers, our research centers.

With a small cut in NIH funds, a small cut in Medicare payments, a small cut in the subsidies for training doctors in what are called ‘DSH payments,’ it would not take much to collapse academic health centers. Then as a society, we would need to ask, “Do we want to bail them out? Are we getting our money’s worth?”

DUBNER: The humanist in me and just the plain old human in me agrees with you entirely about the desire and need to change and/or collapse the current model. On the other hand, our health care spending is something close to, I believe, 20 percent of GDP now. Is that right?


DUBNER: I look at that as if it’s a mafia of some kind that’s got a stranglehold, that’s got so much money flowing from so many different directions, with so many different avenues of revenue, many of which, as you’ve pointed out, are counterproductive and maybe even dangerous. Maybe I just don’t have the imagination to envision what public response to that would collapse the system with so much at stake. Can you tell me how to get that picture in my mind?

BRENNER: No one in the C.I.A. could imagine Mubarak ever being out of power, right? Complex, adaptive systems go through state changes and they do it in very complex and unpredictable ways. One day they’re one way and the next day there’s been a dramatic shift. The way that you undermine a complex, adaptive system is you begin to undermine the inputs that sustain it. The inputs that sustain complex adaptive systems are energy, money [and] goodwill, and the health care system is doing a very good job of eroding all of those things. I don’t know when it’s going to happen. I don’t know exactly how it’s going to happen, but it’s a very brittle system. It’s a very leveraged system. It’s hurting more and more people not through, I don’t think an act of commission, but an act of omission. Its own complexity, now, is injuring people.

The number of times I’ve been behind the scenes, in a legislator’s office and this heartrending story pours out of them about their own parents. As the baby boomers are aging, people in their 40s are caring for their parents and watching what the system does to them. There’s going to be a growing anger as the co-pays, deductibles and employee contributions get higher and higher. The goodwill underpinning the system is going to begin to break down. There comes a point in a system in America where it no longer serves any of the purposes that it was originally set up to serve. America does disrupt things. I don’t see a lot of horse and buggy manufacturers. I don’t see the steel industry here, right? No one saved Blockbuster. There will come a point when, sooner or later, we’re going to let this thing go.

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